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© 2004 European Association of Cardio-Thoracic Surgery
Successful in situ repair of a symptomatic left main coronary artery aneurysm by a saphenous vein graftDepartment of Cardiothoracic and Vascular Surgery, Friedrich-Schiller-University Jena, Bachstrasse 18, 07743 Jena, Germany
* Corresponding author. Tel.: +49-3641-93-48-01; fax: +49-3641-93-48-02 Received October 6, 2003; received in revised form January 22, 2004; accepted February 4, 2004
In a male patient, presenting with progressive angina refractory to medical treatment, a solitary aneurysm of the left main coronary artery without fistula, a 2 cm large atrial septal defect (ASD) and a persisting left superior caval vein were diagnosed. Successful resection with subsequent in situ repair by vein grafting of the left anterior descending artery and the circumflex coronary artery system and direct closure of the ASD are described.
Key Words: Coronary artery aneurysm; Atrial septal defect; Coronary vessel anomalies
Coronary artery aneurysms are seldom with a described incidence of 1.2–4.9% in patients undergoing coronary angiography [1,2]. However, most patients suffer from multivessel involvement and isolated aneurysms of coronary arteries without fistula are extremely rare [2,3]. We present the in situ repair of a solitary aneurysm of the left main coronary artery using a saphenous vein graft.
A 60-year-old man was admitted to a district hospital for evaluation of episodic progressive chest pain refractory to antiischemic medical therapy (i.v. nitrate). Otherwise the patient had been in good health without any known cardiac abnormalities and without history of cardiovascular disease. Routine laboratory tests were normal. The ECG demonstrated atrial flutter and a right bundle block. Coronary angiography revealed a large solitary aneurysm (20x15 mm, Fig. 1) of the left main coronary artery and an ectasia (6–8 mm) of the entire right coronary artery. The circumflex coronary artery (CX) was normal. A 2 cm atrial septal defect (ASD) and a persistent left SVC were accidental findings following admission in our institution.
We decided to operate on this patient due to his progressive, conservatively not treatable angina, closing simultaneously the large ASD. Briefly our surgical strategy included the exclusion of the aneurysm either by clipping or by complete resection. In case of clipping revascularisation should be performed by grafting the left anterior descending (LAD) with the left internal thoracic artery (LITA) and of the CX system by a saphenous vein bypass. If resection could be achieved surgical repair should be done by a direct anastomosis of a saphenous vein bypass end-to-end to the bifurcation of the left main coronary artery. Following harvesting of the LITA and bicaval and aortic cannulation cardiopulmonary bypass was established. The persistent left SCV was temporarily occluded without increase of the SVC pressure. Retrograde cardioplegia was administered. The aneurysm began approximately 5 mm distal to the origin of the left main coronary artery at the aorta. It was isolated from the surrounding tissue by sharp dissection up to the bifurcation of the left main coronary artery. Since direct exclusion and end-to-end anastomosis was not feasible subsequently the left main coronary artery was ligated at its origin and transsected at its bifurcation. This resulted in a complete exclusion and removal of the entire aneurysm. A reversed segment of saphenous vein was end-to-end anastomosed with the bifurcation using a 7–0 Prolene running suture (Fig. 2) Passing on the backside of the pulmonary artery and the ascending aorta the graft was anastomosed to the ascending aorta on its right lateral side. We choose to route the graft behind the aorta in order to avoid kinking. Then the LITA was connected with the LAD end-to-side. Additional evaluation of distal circumflex artery branches showed an extremely thin periphery without any possibility for grafting. After consecutive direct closure of the ASD the heart was de-aired and the patient weaned of cardiopulmonary bypass. Venous bypass flow revealed 190 ml/min. The ECG demonstrated normal ventricular complexes without signs of ischemia. The postoperative recovery was delayed due to respiratory insufficiency and a transit psychoorganic syndrome. Fifteen days after the operation the patient was referred back for further recovery to the district hospital in good health.
Daoud's series in 1963 as well as Falsetti in 1976 found atherosclerosis in 52 and 50%, respectively, as the most common etiology [1,2]. Further causes are congenital, mycotic, postsyphilitic, posttraumatic (including coronary angioplasty), in association with connective tissue disorders and some other rare etiologies [1–3]. In our case no arteriovenous fistula was detected. Histology revealed atherosclerotic alteration of the vessel without any signs of a specific inflammation, resulting in a most likely atheroslerotic etiology in this case. Despite the coexistence of a congenital defect (ASD and left persisting SVC) there is no evidence for an association of coronary aneurysms with these malformations. Coronary aneurysms occur most frequently in the right coronary artery (approximately 50%) and only in 10% of cases in the left main coronary artery [1,2,4,5]. However, the case of a large isolated aneurysm in the left main coronary artery causing angina is extremely rare. In 1971 Ebert [6] excised a solitary large aneurysm of the CX and interposed a reversed segment of saphenous vein autograft. In 1978 Leguerrier [7] ligated a left main coronary aneurysm immediately proximal to the bifurcation without resection maintaining the circulation by vein grafts. In 1991 John [8] clipped the solitary aneurysm of lateral circumflex artery followed by reconstruction of the blood stream by a saphenous vein bypass graft to the distal vessel. In 1999 Harandi [9] presented an overview about the so far published surgical techniques: apart from the above-mentioned principles of surgical treatment he added thrombectomy and aneurysmorhectomy (marsupilization). We did not consider thrombectomy or thrombolysis as a true alternative treatment modality as these procedures do not eliminate the cause of thrombus formation—namely the aneurysm or the diseased vessel. Furthermore there is no real evidence for the efficiency of consecutive anticoagulation therapy in the literature. Potential coated stent exclusion might be an interventional cardiologist approach. However, potential thrombus dislocation and embolisation remain an unsolved issue. Accordingly we choose to resect the aneurysm. We believe that exclusion is necessary to prevent potential rupture and dissemination of thrombus material. Maintenance of the circulation with maximal possible flow to the distal vessel is best accomplished by an end-to-end anastomosis. That implied the resection of the aneurysm. Since the LITA was harvested and for security reasons in case of a future thrombotic occlusion of the vein bypass it was anastomosed with the LAD despite an excellent flow in the vein graft. In conclusion this is the first reported case of a successful resection and in situ repair of a left main coronary artery aneurysm. doi:10.1016/j.icvts.2004.02.020
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Abstract
1. Introduction
